Provider Demographics
NPI:1639527393
Name:RADICAL REALNESS THERAPY LLC
Entity Type:Organization
Organization Name:RADICAL REALNESS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRZESINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:971-930-0089
Mailing Address - Street 1:5131 N LINCOLN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2584
Mailing Address - Country:US
Mailing Address - Phone:971-930-0089
Mailing Address - Fax:
Practice Address - Street 1:510 SW 3RD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2543
Practice Address - Country:US
Practice Address - Phone:971-930-0089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1159106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty